Ankle Arthroscopy & Ligament Reconstruction

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Introduction

Ankle arthroscopy is an excellent, minimally invasive procedure that allows thorough visualisation of the ankle joint. It proves useful for diagnosing and treating various conditions affecting both the interior and exterior of the ankle joint.

During the procedure, a small fibre-optic telescope called an arthroscope is inserted into the joint. The arthroscope is equipped with a camera, which allows the surgeon to visualise the internal structures of the ankle. The images captured by the camera are displayed on a TV monitor, enabling the medical team to carefully evaluate and address the specific issues present.

Most arthroscopic surgeries are performed as day procedures, meaning the patient can typically return home the same day. The surgery is usually conducted under general anaesthesia to ensure the patient’s comfort and safety throughout the operation.

Please find below more detailed information on the ankle arthroscopy procedure, including what to expect prior to, during, and after the surgery, as well as information on the recovery period.

Indications and Contraindications

Ankle Arthroscopy Indications

Ankle arthroscopy can be used alone or in conjunction with conventional surgery to address various injuries and conditions affecting the ankle joint. Some of the most frequently treated ankle conditions using arthroscopy include:

Arthritis and cartilage damage: Ankle arthroscopy can offer a minimally invasive way to perform debridement (cleaning) or more complex interventions, like an ankle fusion.

Fractures: Arthroscopy, combined with open techniques, can ensure proper bone and cartilage alignment during fracture repair. It can also identify and address cartilage injuries inside the ankle.

Synovitis: This refers to the inflammation of the ankle’s lining (synovium), leading to pain and swelling. Removal of excessive synovium can be performed.

Loose bodies of bone and cartilage: These can cause clicking and catching sensations within the ankle joint, and should be removed.

Ankle instability: Arthroscopy can help tighten ligaments surrounding the ankle joint, reducing the feeling of the ankle giving way.

Anterior ankle impingement: Inflammation of the soft tissue at the front of the ankle joint, often seen in athletes or football players. Arthroscopy can remove inflamed tissue and bone spurs.

Posterior ankle impingement: This occurs when the soft tissue at the back of the ankle becomes inflamed and makes pointing the foot down painful. This condition is commonly seen in dancers. The tissue causing the pain can be removed using arthroscopy.
Unexplained ankle symptoms: Arthroscopy allows direct visualisation of the joint, facilitating the identification of previously undiagnosed symptoms and problems.

Contraindications for ankle arthroscopy may include:

Severe Infection: If there is a severe infection in or around the ankle joint, ankle arthroscopy is typically contraindicated.
Severe Vascular Disease: Patients with severe vascular disease that affects blood circulation in the ankle area may be at higher risk for complications during and after the procedure.
Severe Coagulopathies: Individuals with severe blood clotting disorders (coagulopathies) may be at a higher risk of excessive bleeding during the procedure.
Advanced Osteoarthritis: Cases of advanced osteoarthritis with significant joint destruction and deformities, are not candidates for minimally invasive surgery.
Severe Bone Loss: Extensive bone loss or bone deformities may limit the effectiveness of ankle arthroscopy.

Benefits and Risks of Ankle Arthroscopy

Ankle arthroscopy offers numerous benefits, including smaller incisions, reduced scarring, minimal tissue damage, faster recovery, and a decreased risk of complications. Patients undergoing ankle arthroscopy typically experience less pain and a quicker return to daily activities compared to patients undergoing traditional open surgery.

Risks of Ankle Arthroscopy Surgery

Infection: As with any surgical procedure, there is a risk of infection. The surgical site must be kept clean and monitored for signs of infection, such as redness, swelling, or increased pain.
Bleeding: Ankle arthroscopy may result in bleeding into the joint.
Nerve and Blood Vessel Damage: There is a risk of damage to nearby nerves or blood vessels during the procedure, which can lead to sensory or motor deficits. This risk is generally low but needs to be carefully managed.
Deep Vein Thrombosis (DVT): Prolonged immobilization after surgery can increase the risk of deep vein thrombosis, a blood clot in the deep veins of the leg. Measures like compression stockings and early mobility help reduce this risk.
Stiffness and Swelling: After ankle arthroscopy, patients may experience stiffness and swelling in the joint. Physical therapy and proper post-operative care are essential to manage these symptoms.
Adverse Reactions to Anaesthesia: Anaesthesia carries its own set of risks.
Failure to Diagnose or Treat: In some cases, ankle arthroscopy may not provide a clear diagnosis or treatment due to the complexity of the issue. Additional procedures or open surgery may be required.
Delayed Recovery: While ankle arthroscopy generally results in a quicker recovery compared to open surgery, some patients may experience delayed recovery or persistent symptoms.
Scarring: Although the incisions for ankle arthroscopy are small, scarring can occur. The appearance of scars can vary depending on individual healing and care.
Incomplete Resolution of Symptoms: In some cases, the surgical procedure may not completely resolve the patient’s symptoms or may require further intervention.

Surgical Approach

The surgical approach for ankle arthroscopy is considered minimally invasive, resulting in shorter recovery times and less post-operative pain compared to open surgery. The specific techniques and procedures employed during ankle arthroscopy can vary based on the patient’s condition and the surgeon’s recommendations.

Pre-Surgery Information

Prior to ankle arthroscopy surgery, several preparatory steps are taken:

Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and local condition.
Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. The patient will need to cease aspirin or anti-inflammatory medications 10 days before surgery, as well as any naturopathic or herbal medications.
Examinations: X-rays are taken, and in some cases, a CT scan or MRI may be necessary to assess the extent of the injury and damage.
Discussion: A thorough discussion with both the patient and their family to understand the procedure, potential outcomes, risks and expectations.
Skin preparation: On the night before and the morning of the operation, the patient is required to wash their leg with a sponge provided in the pre-admission clinic. Occasionally, a Betadine Skin test is used if there is suspicion of an allergy to iodine.
Bowel Prep: Glycerin suppositories are provided at the pre-admission clinic, and patients need to administer them the evening before surgery (an instruction leaflet is given at the pre-admission clinic).
Patient education: The physiotherapy assessment will include instructions on gait training, the use of crutches, and pre- and postoperative exercises. The patient will also be fitted with crutches to take home and practise preoperatively.

Day of Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be provided, and the operation site will be shaved and cleaned.
A Betadine skin prep will be applied to the area above the ankle and wrapped.
All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

The Ankle Arthroscopy Process

Once the anaesthetic has been administered, the ankle is prepared in a sterile manner, and a tourniquet is placed around the thigh to help with visualisation and minimise bleeding.

The arthroscope, a small instrument about the size of a pen, is then inserted through a small incision into the ankle. Additionally, incisions are made to introduce specialised instruments for joint examination and treatment.

A fluid is then pumped through the arthroscope to ensure a clear view and control any bleeding.

Images of the ankle’s interior are projected onto a TV monitor, providing a detailed view of the joint.

After a thorough evaluation of the ankle joint, the surgeon can determine the appropriate treatment. Once the cause of pain is established, they can use the inserted instruments to perform precise tasks like shaving off torn cartilage, trimming bone spurs, and removing inflamed tissue.

Ligament repair or reconstruction can be also performed, if necessary.

The duration of the procedure may vary based on the findings and extent of the required treatment. Once the arthroscopic phase is completed, the incisions are typically sutured and covered with adhesive tape. Protective bandages are then applied and a plaster cast might be necessary to support the healing process of the ankle.

Post-Surgery Information

Ankle Arthroscopy is typically a day-surgery procedure.

The provided pain medication should be taken as directed.

The patient should mobilise and put weight on the leg with crutches as advised by the surgeon. This will depend on the type of reconstruction performed.

The patient may walk on the operated leg according to pain limits. The bandage can be removed after 24 hours, and the provided waterproof dressings can be placed over the wound.

It is normal for the ankle to swell after the surgery. The patient should elevate the leg when seated and apply an ice pack to the ankle for 20 minutes, three to four times a day, to reduce swelling.

A follow-up appointment with Dr. Al Muderis will be scheduled 7-10 days after surgery to monitor the patient’s progress and remove stitches.

Strengthening exercises can be commenced as per the surgeon’s protocol. The patient can resume sports and most other physical activities usually after 3-6 months.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000